Just fifty-four weeks after services were rendered, Blue Cross Blue Shield of Massachusetts (BCBS) has issued payment for my jaw surgery. They paid quite a good sum of money, too. They actually issued a check directly to my father, who is the subscriber for the policy, in the amount of $2976, which is what they determined their liability to be. That’s about $1000 more than I’ve paid to the oral surgeon.

Presumably what happens from here is that my other insurance plan will learn that they’ve overpaid and request that the oral surgeon return some amount of their money. I’ll then have to send the oral surgeon a check for that amount.

It wasn’t so long ago that I wondered whether my time spent on the phone with BCBS would save me any money at all. For a while, they were telling me that SHIP had already paid more than they would have paid. Between that and SHIP’s non-duplication of benefits policy, it seemed like I might have already hit a ceiling for the combined payments of those two insurers.

With this development, though, I’ll save roughly $1200, even if SHIP decides that they shouldn’t have paid anything. Needless to say, I’m pretty happy right now.

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If, like me, you have two or more health insurance policies, the order in which the policies pay is determined through a process called coordination of benefits, which in Massachusetts is governed by regulation 211 CMR 38.00 [pdf].

In my case, it gets a little bit complicated because my two policies are from different states. I haven’t looked at California coordination of benefits regulations, but if they differed significantly from the Massachusetts policy it would be possible to have a situation in which neither plan (or both plans) were obligated by their respective state laws to pay as the primary insurer. For now, though, I’m just going to look at the Massachusetts regulation.

A number of my providers incorrectly billed my UC Berkeley Student Health Insurance Plan (SHIP) first. My oral surgeon’s billing person even tried to tell me that I was wrong when I insisted that my parents’ policy should have been billed as the primary insurance. At a glance, it might seem that she is right (211 CMR 38.05):

(3) The benefits of the plan which covers the person as an employee, member or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent.

I’m not exactly covered by my Blue Cross Blue Shield as a dependent but as a former dependent, since the Massachusetts insurance reform allows young people to keep their parents’ insurance for two years after loss of dependency or until age 26 (whichever is first). Still, I’m definitely the subscriber for my SHIP coverage, so it would be tempting to say that this means that my student plan is primary.

However, turning to the definitions section of the regulation (38.03), we find the following (emphasis mine):

Plan: a form of coverage with which coordination is allowed. The definition of plan in the group contract must state the types of coverage which will be considered in applying the COB provision of that contract.

…Plan shall not include:
(a) nongroup coverage except for coverage described in 211 CMR 38.03: Plan(d) through (f) above, or when a nongroup plan chooses to coordinate with other nongroup plans;
(b) Medicare or other governmental benefits except to the extent permitted by law;(c) student accident coverages, Qualifying Student Health Insurance Programs (“QSHIPs”) or other student health plans when designated as “excess only” or “always secondary plan”;and
(d) a plan under Medicaid, or any other plan when, by law, its benefits are secondary to or in excess of those of any private insurance plan or other nongovernmental plan.

In other words, the coordination of benefits regulations don’t apply to student insurance plans, so long as those plans specifically designate that they are secondary to other coverage (as SHIP does). When the regulation refers to “the plan which covers the person as an employee, member or subscriber,” my coverage under SHIP is not included, because SHIP–although it covers me as a subscriber–is not included in the word “plan.”

It’s easy to see where providers would get this wrong. When I filled out paperwork, I had to specify the name of the policyholder, but I never had to indicate whether the policy was a student health plan. From the information they had, was reasonable (but incorrect) to guess that my SHIP plan was primary.

The coordination of benefits regulations don’t just determine which insurance company has to pay first. They also determine how the benefits are calculated. This brings me to the point that I found myself repeating over the phone with BCBS on Friday (38.05):

(1) The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist. A plan that does not include a coordination of benefits provision may not take the benefits of another plan into account when it determines its benefits. There is one exception: a contract holder’s coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder.

The one exception doesn’t seem to apply here, so the regulation requires that BCBS pay its benefits as if there are no secondary plans. That might seem to imply that they can’t take into consideration the fact that another plan has paid benefits (even if that plan was billed incorrectly), since a plan that doesn’t exist certainly doesn’t pay benefits.

However, there is something of a loophole here. As quoted above, the regulation doesn’t state that student plans are secondary plans. It says that, for the purpose of coordination of benefits, they should not be considered plans at all. Thus, BCBS could argue that they aren’t prohibited from taking the existence of my SHIP coverage into consideration because SHIP isn’t included when the word “plan” is used in this paragraph. Such an interpretation would seem to be contrary to the spirit of the regulation, but it may well be consistent with the letter of the law. I hadn’t thought of this when I was on the phone with BCBS, so I guess I’m just lucky that she didn’t know the law and considered it irrelevant.

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By the time fall came around, I had assumed that my insurance had paid all of my bills since I hadn’t received any more. It turns out that I was wrong; they were just very slow to reject a couple of claims. Specifically, my parents’ insurance has rejected claims from Berkeley Emergency Medical Group and the oral surgeon.

The balance with Berkeley Emergency Medical Group was only $76.30, but I haven’t gotten a bill from them yet. The oral surgeon’s bill is much bigger, nearly $2,000, because it was out-of-network for both of my insurances. The oral surgeon’s office also seems to be in a bigger hurry to get money from me. I’ve received a bill from them as well as a couple of phone calls.

The billing person at the oral surgeon’s office told me that my claim was rejected because of a non-duplication of benefits policy. However, when I called the insurance company, they seemed to be telling me that they had rejected my claim simply because they didn’t know anything about my other insurance and thus couldn’t determine how much they should pay. So I gave them the information for my other insurance, and they told me that they’d take 30-45 business days to figure things out and then process the claims again. That was about 26 business days ago, so I’ll call them again at the end of this week.

I also authorized a partial payment to the oral surgeon’s office, since I don’t want that balance turned over to a collections agency. The oral surgeon’s office seems thoroughly confused about this situation, and I really think they underestimate how much my insurance will owe. This is, after all, my primary insurance, but the oral surgeon’s office billed the other one first.

I’ve started to wonder why I was referred to this oral surgeon from the emergency room if it was out-of-network for my insurance. One possibility is that it was because the emergency room had my insurance information wrong, initially billing Blue Shield of California instead of any insurer with which I actually had a policy. Next time I talk to the oral surgeon, I’ll ask if they’re in network for Blue Shield of California. Of course, it’s also entirely possible that the emergency room just doesn’t have a policy of referring within network.

When I posted my last update, I had just emailed my second insurance information to Berkeley Emergency Medical Group and Bay Imaging Consultants. The next morning, I received an email from Bay Imaging Consultants informing me that they had billed the second insurance. I have still heard nothing from Berkeley Emergency Medical Group.

I received a bill from Alta Bates Summit Medical Center for my treatment. The total amount was $1,944.10, but insurance adjustments decreased that by $505.45 and insurance payments knocked off an additional $1,413.65, leaving me to pay only $25. I plan on paying this amount by credit card in a few weeks so that it will go on my August statement rather than July. I have the money in my account, but I might as well earn interest on it for another month.I also requested an itemized bill from Alta Bates by phone, and this arrived on Friday. I haven’t found it very helpful, though. It does have a charge of $16.72 for “ORAL/IBUPROFEN 600MG T”, which I’m not sure I received. It’s possible that it’s something they had me take some in the hospital (but sixteen dollars worth?), but I definitely didn’t take a bottle home with me. The doctor actually gave me a prescription for ibuprofen, but the pharmacist told me to just buy it over the counter. I don’t plan on looking into this because I don’t think it would affect the amount I pay after insurance.

Incidentally, neither the original bill nor the itemized bill tells me which insurance paid, but I think it’s my father’s insurance because I did tell Alta Bates that his insurance was primary.

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With my recovery nearly complete, my posts here will be less frequent than they once were. I’ll still be posting about billing and insurance when there’s news on that front. I’ll also post updates on any new developments with my injuries if and when things arise. Eventually, I’ll get around to posting about some of the things I’ve learned from my accident and its aftermath (including a guide for those who are recovering from similar injuries) and how my experiences have influenced my worldview.

In the mean time, there are a few things that I probably should have mentioned a while ago. I’ll post three here. I may include more in subsequent posts.

Some time after I returned from my oral surgery, I found an x-ray of my mouth among the things that I had carried home from the surgeon’s office. I have never had any recollection of the taking of the x-ray, but it was apparently done after I had my mouth wired, as the wires are visible. Here it is. Note that the left side of my mouth (with the fracture) appears on the right side of the image.

It seems that I’ve neglected to explain that the part of my jaw that I broke, the condyle (or maybe it was the neck of the condyloid process, just below the condyle) is located near the joint with the upper jaw, rather than near the teeth. I suspect that this made the recovery easier than it otherwise might have been because the pictures of jaws broken between the teeth look far more gruesome than anything I saw on my own face.

A few days after the oral surgeon wired my mouth shut, my mother mentioned to me that she had read that people who have their jaws wired shut often have to carry wire cutters for emergency use. I had no recollection of the oral surgeon saying anything to me about wire cutters, but I could not rule out the possibility that he had said something but I could not remember because I was still feeling the anesthesia. Furthermore, some research showed that my mother’s claim was correct. Moreover, I discovered a few days before my wireless upgrade that the instructions I received from the hospital said,

If your jaw was wired shut, it is important that you be able to open the wires in any emergency that makes it difficult to breathe, such as vomiting, extreme coughing or choking. Therefore, you must carry a pair of small wire-cutters with you at all times. Be sure you know which wires to cut in case this is necessary. If not, ask your doctor.

To be clear, this came from the hospital, and I had my jaw wired a few days later by an oral surgeon at a different practice. But I never carried a wire cutter. I’m still alive today. Go figure.

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I went in to the oral surgeon’s office today expecting to learn some new jaw exercises. In view of my recent reading, I was somewhat skeptical of the idea that my opening was actually going to get better, so I showed up prepared to ask whether it was reasonable to

When the oral surgeon came into the examination room, he asked me how my opening was. I started to answer before he clarified that he wanted to see it. I opened my mouth, and to my surprise, he told me that it was better than he expected. He added that most people can put three fingers in their mouth, and then demonstrated by trying to put three of his fingers in his mouth. The third one didn’t really fit, though. He had me try to do the same, and I was able to put two fingers in easily, but my opening wasn’t wide enough for a third finger. The oral surgeon said it was close enough, demonstrated with his fingers that it was only a millimeter or two from normal, and then watched as I opened and closed my mouth a couple of times to make sure that it was opening straight. He said that I “totally qualify” to have my braces taken off and asked if I wanted them removed right then. I wanted little more, so I answered in the affirmative.

The oral surgeon told me that the wires around my teeth would poke my gums as he pulled them out, so he gave me three options for counteracting the pain: nitrous oxide and a numbing gel; nitrous oxide, the numbing gel, and novacaine; or general anesthesia. I chose the first of these options, and the oral surgeon told me that most people can handle it, adding that it was “like having a really mean hygienist.”

The oral surgeon moved me to another room, where an assistant put gauze in my mouth, spread the numbing gel on my gums, and hooked me up with nitrous oxide through my nose. The oral surgeon came into the room and started to say, “The adventure that began in April…”. He said it in this overly dramatic tone that sounded like it might have come from one of Barack Obama’s speeches (video; see 9:44), but the second half of the oral surgeon’s sentence, “…comes to a close,” was decidedly less dramatic. He then took the gauze out of my mouth, told me to open my mouth, and cut each of the wires on the top of my mouth before pulling them out. It hurt a little bit, but the pain went away when the wire was out, so it wasn’t bad. At this point, I realized that I had actually started breathing through my mouth again, and I wasn’t feeling the nitrous oxide as much. The oral surgeon then removed the bottom wires. Somewhere in the middle of removing the bottom wires, I noticed that I was sweating a lot, but I don’t know if this was nervousness, an effect of the numbing agents, or a result of the room actually being hot.

The oral surgeon turned off the nitrous oxide and turned on a supply of oxygen, and told me that I didn’t need to return to his office, but I could call if I had concerns. He added that I’d be ready to chew the hardest foods (which he identified as crisp apples, hard French bread, and very hard vegetables) around July 4. The assistant gave me a toothpaste and toothbrush and had me brush my teeth. I had brushed before going, so there wasn’t anything but blood on them, but I complied anyway. The assistant told me that my gums would bleed easily for the next two or three weeks, but that I shouldn’t let this keep me from flossing.

Finally, I have some pictures. First up is a picture of my mouth, sans arch bars.

It isn’t perfectly straight, but the appearance of crookedness is exaggerated by the fact that my front teeth are not the same length. The second picture is of me trying to stuff my fingers in my mouth.

I tried to stick my fingers in my mouth. I suppose this endeavor was made slightly easier by the fact of my having slender fingers.

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I just got back from my routine six-month cleaning at the dentist’s office. I only saw a hygienist; the dentist didn’t look at my mouth. To my relief, she didn’t find any cavities. She told me that one of my back teeth has a deep groove in it that will need to be brushed extra carefully, but she emphasized that this was the anatomy of the tooth rather than a cavity.

When my mouth was wired shut, I was unable to brush most surfaces of my teeth, so I find it quite remarkable that I don’t have any cavities. A large part of this, as the hygienist pointed out, is that I’m lucky to have hard enamel. What I don’t owe to luck, I owe to my WaterPik, which proved to be an absolutely indispensable tool for cleaning my teeth and the wires around them.

I also learned that the dentist’s office has already billed my second insurance for the rest of the charges on my account. I should be receiving a bill for whatever they don’t pay in a few weeks. The statement of benefits from the insurance company, however, will probably go to my parents’ address.

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About

I'm Adam Merberg. I wrote this blog after I had a bicycle accident and thought it might be useful to document the various injuries (a broken jaw among them) that resulted. If you have questions about anything you read here, feel free to email me. These days, I don't update this blog often because I consider myself to be fully recovered, but I do try to reply to comments and emails.

Please note that this blog is not a substitute for professional medical advice or treatment. If you have reason to believe that you have broken your jaw, you should see a doctor.